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Smokeless tobacco cessation: South Asian communities

About

What is covered

This interactive flowchart covers interventions to help people of South Asian origin who are living in England to stop using smokeless tobacco products.
The phrase 'of South Asian origin' is used to mean people with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka.
People of South Asian origin are the focus, as they are the predominant users of smokeless tobacco products in England. Others who use these products may also benefit from the recommendations, as health professionals, as a result, will be more aware of how to identify and help them.
Some of the interventions may also help stop people from taking up the habit in the first place. For example, they may help young people who are experimenting with tobacco to give it up before they become addicted.
The recommendations have been made within the context of local tobacco control strategies, including the provision of local services and initiatives to prevent the uptake of tobacco and help smokers and other tobacco users to quit.
They should be implemented as part of other activities and services to address the general health needs of South Asian communities.
The interactive flowchart is for tobacco cessation services (including stop smoking services), health education and training services, health and wellbeing boards and health and social care practitioners. It is also for all those with public health as part of their remit, in particular, the health of South Asian communities.
It may also be of interest to local authority elected members, people who want to stop using smokeless tobacco, their families and other members of the public.

Updates

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on helping people of South Asian origin to stop using smokeless tobacco products in an interactive flowchart

What is covered

This interactive flowchart covers interventions to help people of South Asian origin who are living in England to stop using smokeless tobacco products.
The phrase 'of South Asian origin' is used to mean people with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka.
People of South Asian origin are the focus, as they are the predominant users of smokeless tobacco products in England. Others who use these products may also benefit from the recommendations, as health professionals, as a result, will be more aware of how to identify and help them.
Some of the interventions may also help stop people from taking up the habit in the first place. For example, they may help young people who are experimenting with tobacco to give it up before they become addicted.
The recommendations have been made within the context of local tobacco control strategies, including the provision of local services and initiatives to prevent the uptake of tobacco and help smokers and other tobacco users to quit.
They should be implemented as part of other activities and services to address the general health needs of South Asian communities.
The interactive flowchart is for tobacco cessation services (including stop smoking services), health education and training services, health and wellbeing boards and health and social care practitioners. It is also for all those with public health as part of their remit, in particular, the health of South Asian communities.
It may also be of interest to local authority elected members, people who want to stop using smokeless tobacco, their families and other members of the public.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Smokeless tobacco: South Asian communities (2012) NICE guideline PH39

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Brief interventions involve verbal advice, discussion, negotiation or encouragement, with or without written or other support or follow-up. They can be delivered by a range of primary and community care professionals. These interventions are often opportunistic, typically taking no more than a few minutes for basic advice, up to around 20 minutes for a more extended, individually-focused discussion. They may also involve a referral for further interventions or more intensive support.
Evidence shows that a brief intervention to help people quit smoking can be effective. The way a brief intervention to help smokers is delivered depends on a number of factors, including the person's willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following:
  • simple opportunistic advice
  • an assessment of the person's commitment to quit
  • pharmacotherapy and/or behavioural support
  • self-help material
  • referral to more intensive support, such as to an evidence-based smoking cessation service.
See what NICE says on smoking for more information on the general principles of tobacco cessation.

Smokeless tobacco

The term 'smokeless tobacco' is used to refer to any type of product containing tobacco that is placed in the mouth or nose and not burned. It does not include products that are sucked, like 'snus', or similar oral snuff productsAs defined in the European Union's Tobacco Product Directive. . (Under UK law it is an offence to supply tobacco for oral use unless it is intended to be smoked or chewedSee the Local Government Association's Niche Tobacco Products Directory website for further information. .)
The recommendations cover a variety of smokeless tobacco products used by people of South Asian origin in England. The types used vary across the country but they can be divided into three main categories, based on their ingredients (see the BMJ research paper Global surveillance of oral tobacco products: total nicotine, unionised nicotine and tobacco-specific N-nitrosamines):
  • Tobacco with or without flavourants: misri India tobacco (powdered) and qimam (kiman).
  • Tobacco with various alkaline modifiers: khaini, naswar (niswar, nass) and gul.
  • Tobacco with slaked lime as an alkaline modifier and areca nut: gutkha, zarda, mawa, manipuri and betel quid (with tobacco).
Users do not always recognise the term 'smokeless tobacco'. Sometimes they will be unaware that the products contain tobacco (although the products are legally required to carry a health warningSmokeless tobacco products are required to carry the warning: 'This tobacco product can damage your health and is addictive' on the most visible surface of the packet. Refer to the Local Government Association's Niche Tobacco Products Directory website for further details.). That is why it is also necessary to refer to these products by the names used locally.
A number of the products contain areca nut, a mildly euphoric stimulant which is addictive and carcinogenic in its own right. (Any chewable products that do not contain tobacco are the responsibility of the Food Standards Agency. The Agency is currently working with UK Asian communities to provide guidance on how to minimise the risk from consuming products containing areca nut.)

Glossary

in these recommendations, the term 'South Asian' refers to people with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka
in these recommendations, 'Specialist tobacco cessation service' refers to evidence-based services that offer tobacco users support to help them quit (regardless of whether they smoke or use a smokeless variety). In England, services of this type are generally referred to as 'stop smoking services' or 'smoking cessation services', as they normally focus on people who smoke tobacco. However, a service might also brand itself as a generic tobacco cessation service, to emphasise a focus on more than one form of tobacco. For further details, see stop smoking services in NICE's recommendations on smoking.
evidence-based services that offer tobacco users support to help them quit (regardless of whether they smoke or use a smokeless variety). In England, services of this type are generally referred to as 'stop smoking services' or 'smoking cessation services', as they normally focus on people who smoke tobacco. However, a service might also brand itself as a generic tobacco cessation service, to emphasise a focus on more than one form of tobacco. For further details, see stop smoking services in NICE's recommendations on smoking.

Paths in this pathway

Pathway created: September 2012 Last updated: May 2017

© NICE 2017

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